Vertigo and Dizziness in Post Concussive Syndrome
Nellie is a 12-year-old girl hit by a sailboat boom a month ago. She did not pass out, but has persistent headaches, fatigue, dizziness and nausea. Read more about her initial injury in "Anatomy of a Concussion" and then about the treatment of her "Post Concussive Syndrome (PCS) and Headaches" here. Now, we will discuss the cause and treatment of Nellie's vertigo.
The Semicircular Canals in Nellie's Ears
Nellie's body in space is a thing of elegance, a constantly choreographed and exquisitely timed dance between her eyes and the vestibular organs in her ears. If there is a disconnect between her eyes telling her she is moving and her ears telling her she is stationery -- common when in the back seat of a car looking out at scenery speed by -- she gets dizzy enough to vomit. Some people are more prone to this and Nellie's parents had gotten into the habit of strapping her into the middle seat of the car even when she was a small child, sandwiched between her two brothers. This kept her looking ahead, a simple trick to overcome this disconnect. Ballerinas call a similar trick "pointing," which prevents them from tumbling over during their graceful pirouettes.
Unfortunately for patients with PCS, these tricks won't work because the vertigo in PCS is from a mechanism that is different from the simple disconnect in stimulus input in the above mentioned situations. To understand the source of Nellie's PCS dizziness, it's helpful to understand how her brain uses her vestibular organs detect motion.
Nellie's brain detects motion from three little C-shaped tubular canals in each ear, carved into the thicker bony parts her skull, like labyrinths. These canals are placed, just like in high school geometry, perpendicular to each other along the x, y and z axes so that all computations of spatial dimensions can be accounted for. These three canals, deep inside each ear (six in total) are all filled with a viscous fluid that moves slowly when we move. The movement of this fluid sways these hair cells with their large calcium carbonate crystal heads, adding weight and gravitas to the sway of the hairs -- think of sunflowers swaying in the wind. This allows Nellie, even with her eyes closed, to know if she is upside down or right side up.
When she played "Ring Around the Roses" as a little girl, she gave the fluid, and thus the hair cells, momentum. When she and her friends stopped suddenly, they got dizzy and collapsed in a laughing heap to the floor. This was because of the continued sensation of movement when there is none, as the fluid in the little girls' ears stays in motion just a little while longer.
Rogue Crystals in Nellie's Ears
With head injury, these crystals in Nellie's semicircular canals got knocked off and went rogue, rattling around, so the slightest movement, like moving her head from left to right while reading, created a feeling of "dizziness." As if this weren't enough, her eyes, with the fastest muscles in her body, tried to compensate and Nellie began to get eye strain and headaches, particularly after a day at school looking at pixelated screens.
Dizziness is reported by 50 percent of patients, making it the second most common symptom. Nellie, in fact, had been suffering with vertigo for nearly a month when she came to my office.
When Nellie's inner ear and her eyes didn't quite coordinate, her neck muscles stiffened up to try to keep her head steady. Her stiff neck worsened her headache. Also, the increased eye strain from the poor vestibular system increased Nellie's fatigue which worsened headaches, her symptoms heightening as the day wore on. Her vertigo worsens her eye strain, which worsens her headache and her neck muscle spasm, which increases fatigue which worsens her eye strain.... It's a vicious cycle, and Nellie needed help to break out of it.
Dr. John Epley to the Rescue
Help arrived in the form of the elegantly simple Epley procedure, developed by Dr. John Epley in 1980 (2). Through a series of precise head movements, this office procedure moves the crystals to an area of the labyrinth with no neural sensors, safely corralled and rogue no longer. Magically effective, the Epley takes only a few minutes and has an 80-100 percent success rate after a single treatment.
Nellie enjoyed the Epley and hearing about the mechanics of it.
"Crystals in my ear!" she exclaimed. "Awesome!"
After the procedure, Nellie felt immediately much better.
"Things don't move a little when I do any more," she said, amazed.
Over the following month, with her vertigo gone and her headaches improving daily, Nellie was feeling like her old self again. Now all that's left is to convince both a nervous Nellie and her parents that she is safe to go sailing again.
It's important to remember that PCS is rare and that the symptoms, though scary and a detriment to daily life, will resolve in most cases with time and the right treatment.
Note: All patient identifying details have been changed. For the sake of brevity I have addressed only two of the many sequelae of concussion in these articles. Forgive me for the omission of other, equally significant symptoms, particularly cognitive loss. Many thanks to Dana Abrassart, M.S. for her help with the editing and research of this series.
Selected References:
2) Epley, JM (1980). "New dimensions of benign paroxysmal positional vertigo." Otolaryngology and head and neck surgery 88 (5): 599-605
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